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FOR OFFICE USE: <br /> M <br /> v APPLICATION FOR SANITATION PERMIT <br /> --- ---L` ---- <br /> (Complete in Triplicate) Permit No: .71=V0_.-, <br /> 71 <br /> ------------------- This Permit Expires 1 Year From Date Issued Date Issued .3'_ J!P7�.. <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> p f` <br /> JOB ADDRESS/LOCATION _ _. _ _.. Q:---1.f{ .Irl- -------/_-,- -----------------------CENSUS TRACT --_----_-------------_---- <br /> Owner's Name =----------------------------------------- ---------------------Phone ------------------------------------ <br /> Address -- -C�------------------------------- -------------------------- Ci <br /> Contractor's Name " ________________________________License #/- % Phone 2" _ 2 � <br /> Installation will serve: Residence XApartment House❑ Commercial :❑Trailer Court ;❑ <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units:--_ __-- Number of bedrooms _�?---..Garba_ge Grinder A149__ Lot Size oZA0e-�"��___________________ <br /> k <br /> Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------Private, <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe X Fill Material ------------ If yes, type ___________________________ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) �. <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet) <br /> f <br /> PACKAGE TREATMENT { ] SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Depth ---______________-__._..__ <br /> Capacity ------ ------- ---- Type -------------------- Material---------------------- No. Compartments ------ --------------- <br /> f , Distance to nearest: Well ------------------------------------Foundation -------------- ------- Prop. Line ---------------------- <br /> LEACHING LINE [ ] No. of Lines ________________________ Length of each line---------?------------------ Total Length ________-__--__--_.-________ <br /> 'D' Box __}--------- Type Filter Material --------------------Depth Filter Material ___________ <br /> i <br /> Distance t 1 o nearest: Well _______________________ Foundation --------- -------------- Property Line _._____________._.:.._. <br /> SEEPAGE PIT [ ] Depth ____________________ Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br />} Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line --------- ............ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date _________--._---__-.______________J <br /> Septic Tank (Specify Requirements) -------- ------- ----- ------------ -- r f <br /> ----- -- - - -- <br /> Disposal Field �(Specify'Requirementsi ---- -(, - �l---- -1- �` Erf r ---��, ��----- -- <br /> �� <br /> ---------- - - 2 ------—row X = f---------------- <br /> - -- - ------------------------------------------ <br /> ----- ------- --- -- ----------------------------------- -----------------------------------------------------I--------- -------------=--------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance.of the work for which this permit is issued, I.shall not employ any person in such manner <br /> a. as to become subject to Workmarils Compensation laws of California." <br /> ? Signed - --------------------?to�wner) <br /> --I------------------- ------------ --------------- Owner ' <br /> ----------------------------------------- <br /> By -------------=--------------- � ---- - - - ------'------------------------- Title ---At =- <br /> (If othe <br /> { <br /> ��MENT USE ONLY <br /> APPLICATION ACCEPTED BY ------- --- -- ------- - - - -------- DATE -------.--.------ <br /> BUILDING PERMIT ISSUED ------- --- - -- --- ---- - -------DATE ---- -------------------------------------- <br /> ADDITIONAL <br /> ------------------------•--•--------- <br /> ADIT ONA COMMS -- -- -- -- --- ---------- - -- - ----------------- ,------ ----- ---------- - --------------------------- ----=---------- ---------------- <br /> G <br /> --------------------------------- --------------------------- -------------- - - -- -- - --- ----- -- --------- -- -------------------------------------------------------------------------- <br /> - ----------(_° --- ------ --- --------- --- ----------------------------------------------------- <br /> Final Inspection by s -------------------------- -- - - - ------ - --- --- --- ----- ---------------Date ----� .. ---------- ---------- <br /> SAN <br /> SAN JO N H DI ICT- <br /> E. <br /> CT E. H. 9 1-'6$ Rev. 5M , <br />